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One form to enroll in most benefit programs for employees working 20+ hours per week. Health Insurance Responsibilty Disclosure (HIRD) Form (pdf) Required should an eligible employee decline to enroll in WHOI's medical plan or the "Premium Only" Section 125 Plan. Health Care Flexible Spending Account Reimbursment Form (pdf) Affidavit of Domestic Partnership for Benefits Eligibility (pdf) Required to add your Domestic Partner to coverage. Statement of Termination of Domestic Partnership (pdf) Required to discontinue your Domestic Partner's coverage. Affidavit of Tax Dependent Status (pdf) Required for children over age 19 to determine tax dependent status. Application Form for Personal Computer Loan (pdf) The Institution offers interest-free loans from $300 to $2,500 for the purchase of a personal computer. Application Form for Tuition Loan for Children of Employees (pdf) If you are a regular full-time employee at the Institution, you are eligible for an interest-free loan for the higher education of your children or legal dependents. » Download alternative format - MS Word Child/Dependent Care Expense Reimbursement Form (pdf) Use this form to get reimbursed for dependent care services. » Download alternative format - MS Word Employee/Spouse Work Verification Form (pdf) » Download alternative format - MS Word Dependent Care Subsidy Worksheet (pdf) Use this form to determine how much to deposit into your Dependent Care Assistance Program (DCAP). General2013 Benefits Program Enrollment/Change Form (pdf)One form to enroll in most benefit programs for employees working 20+ hours per week. Affidavit of Domestic Partnership for Benefits Eligibility (pdf) Required to add your Domestic Partner to coverage. Statement of Termination of Domestic Partnership (pdf) Required to discontinue your Domestic Partner's coverage. Employee/Spouse Work Verification Form (pdf) » Download alternative format - MS Word FSA Informational Sheet Direct Deposit Form - Benefit Strategies Health Care FSA Enrollment Form Health/DentalBCBS-MA $150 Fitness Benefit Reimbursement FormAffidavit of Tax Dependent Status (pdf) Required for children over age 19 to determine tax dependent status. Health Care Flexible Spending Account Reimbursment Form (pdf) Health Insurance Responsibilty Disclosure (HIRD) Form (pdf) Required should an eligible employee decline to enroll in WHOI's medical plan or the "Premium Only" Section 125 Plan. Child/Dependent CareDependent Care Reimbursement FormUse this form to get reimbursed for dependent care services. DC-FSA Worksheet Use this form to determine how much to deposit into your Dependent Care Assistance Program (DCAP). DCS Spouse Work Verification Child/Dependent Care Enrollment Form (pdf) Use this form to enroll in the Dependent Care Reimbursement Plan (DCAP)/Dependent Care Subsidy. Loan ApplicationsEmployee Education AssistanceApplication for employee education tuition reimbursement. Application Form for Personal Computer Loan (pdf) The Institution offers interest-free loans from $300 to $2,500 for the purchase of a personal computer. Application Form for Tuition Loan for Children of Employees (pdf) If you are a regular full-time employee at the Institution, you are eligible for an interest-free loan for the higher education of your children or legal dependents. » Download alternative format - MS Word RetirementBeneficiary Form for 403(b) Defined Contribution Retirement Plan (pdf)Use this form to change beneficiary information for your 403(b) Defined Contribution Retirement Plan with Diversified. Beneficiary Form for Defined Benefit Retirement Plan (pdf) Use this form to change beneficiary information for your Defined Benefit retirement benefits. » Download alternative format - MS Word Retirement Estimate Request Form (MS Word) Use this form to notify Human Resources of your actual retirement date or to request an estimate of your retirement benefit under the Defined Benefit Plan. Last updated: June 6, 2013 | |||||||||||||
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